We need to have a clear link in our mind between HAIs and AMR. Infection prevention and control are key actions to reduce antibiotic misuse, fight the spread of resistant bacteria and ultimately save lives.
John Bowis, co-Patron of Health First Europe
The 2nd roundtable debate of the European Network for Safer Healthcare was organised by Health First Europe in the European Parliament on 29 January 2019. With the support of MEP José Inácio Faria (EPP, Portugal) and MEP Lieve Wierinck (ALDE, Belgium), health stakeholders, national representatives and the European Commission, met to discuss the implementation of effective infection prevention and control programmes to reduce healthcare-associated infections (HAIs) and to tackle antimicrobial resistance (AMR).
HAI prevention and control is a core element to tackle AMR. The link between AMR and HAIs is undeniable. Data from the European Centre for Disease Prevention and Control shows that out of 671k infections with antibiotic-resistant bacteria in European countries in 2016-2017, 63% were healthcare-associated infections. Plus, the occurrence of an infection increases the use of antibiotics.
1 in 15 patients in acute care hospital acquires a least one healthcare-associated infection on any given day. Every day these infections result in prolonged hospital stays, long-term disability and high costs for patients, family and healthcare settings. HAIs put a great pressure on health systems, causing significant morbidity and mortality. A total of 8.8 million HAIs were estimated to occur each year in European hospitals and long-term care facilities. More than half of HAIs are considered avoidable through prevention and control programmes. How can we implement successful strategy to save lives and reduce the economic costs related to HAIs and AMR?
MEP Lieve Wierinck, co-hosted of the debate and rapporteur of the European Parliament’s opinion on the Report on the One Health Action Plan against Antimicrobial Resistance(AMR) (2017/2254(INI)) stressed the urgency of this matter “We all know the indication that if we don’t act now, more people will die from AMR than from cancer by 2050”.
According to Andrea Ammon, Director of the European Centre for Disease Prevention and Control (ECDC), infections’ control and prevention is a condition to stop AMR. The key actions needed to be in place to tackle resistant bacteria are:
- Prudent use of antibiotics (only when needed, correct dose, correct dose intervals, correct duration);
- infection prevention and control (hand hygiene, screening, isolation);
- new generation of antimicrobial agents (with a novel mechanism of action, research, development).
But the last one can be effective only with the correct implementation of the first 2 measures.
Surgical site infections (SSIs) and catheter-associated urinary tract infections (CAUTIs) were brought to the center of the debate. CAUTIs and SSIs are the most common HAIs in EU, representing almost 30% of the total burden of HAIs. More than half of these infections are preventable, indicating that lowering the burden of HAIs in Europe is not only an achievable goal but also an imperative. The estimated number of preventable infections and deaths annually is quite significant: for CAUTIs, studies estimate up to 9k of human lives saved, while for SSIs above 4,4k.
The prevention of SSIs is complex and requires the integration of a range of preventive measures before, during and after surgery. Plus, the implementation of these measures is not standardized worldwide. To prevent SSIs, experts suggest developing evidence-based strategies (from hair and wound management to skin antisepsis) along with surveillance programs and alert systems. In order to provide international guidelines and trigger a behavioral change, WHO issued in 2016 its Global guidelines on the prevention of surgical site infection, which were presented by Prof Benedetta Allegranzi, coordinator of WHO infection prevention global unit. However, large inconsistencies and lack on implementation in the of the recommendations in hospital is still too high.
As pointed out by several speakers, both SSIs and CAUTIs require a multidisciplinary approach and a good balance between evidence-based measures and pragmatism. Up to 75% of CAUTIs can be avoided with few actions, from the reduction of the catheters’ size to good maintenance. Specifically, Dr Brigitta Lytsy, (representative of JAMRAI) stressed the importance of bottom-up approach and the damage brought by unnecessary catheters (over 25% of patients in hospitals get a urinary catheter and 60% of all urinary catheters are unnecessary and in place too long).
Dr Jesús Rodríguez Baño, President of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID). remarked three essential actions for implementing successful control strategies: better training for healthcare professionals, quality standards and accreditation, and prioritisation; while safety is a cross-cutting requirement for all the areas. Above all, healthcare professionals’ skillset is the essential ingredient for a successful implementation. Training on operating procedures for decontamination and sterilization as well as a clear definition of competencies for infection control team component can really make a real difference in the quality of care. Also, infection control programmes shall include measurable objectives and indicators, with regular evaluations.
The roundtable was enriched by the contribution of national experts on AMR and HAI screening programmes and surveillance systems from the Netherlands, the UK and Belgium. They presented three important lessons learned in the path for the reduction of AMR/HAIs. First, we shall never underestimate the power of awareness raising campaigns; they have shown great outcomes in reducing antibiotic consumption in ambulatory care and in fostering hand hygiene. Second, the benefits of infection prevention and antimicrobial stewardship teams outweigh the costs. This is an important finding to prove the value for money and consequently call for further investment on stewardship programs. Finally, mandatory HAI surveillance outputs are essential to monitor progress on controlling infections and for providing epidemiological evidence to inform action to reduce them. Data can ultimately support the national healthcare systems objective of improving the quality and safety of services and promoting patient choice by providing access to information on systems’ performance.
In the light of these lessons learned, what can policymakers do to shape and implement effective prevention and control programme? As MEP Faria remarked – while HAI prevention and control are under the remit of the Health Ministries of Member States, EU institutions can still provide a useful political arena to shape future policy and raise awareness on patient safety and HAI prevention. Infections’ management need strong political commitment and clinical leadership that stretches across silos in healthcare provisions.
HFE co-patron, John Bowis, wrapped up the discussion, stressing that working together is critical to tackle public health emergencies such as AMR and HAIs. We need to have a clear link in our mind between HAIs and AMR and that infection prevention and control are key actions to reduce antibiotic consumption.
The European Commission and Parliament shall keep AMR and HAIs prevention and control among the key priorities of the next years in order to ensure the continuation of the EU Action Plan and providing measurable indicators about its implementation. It is important to encourage and support Member States to put in place and monitor national targets for the surveillance and reduction of AMR/HAI through holistic action plans under a “One Health approach”.